Lecture 1- Medication review

Question 1

Why is medication review important

Answer 1

• Half of regular medicines not used in a way tht is fully effective
• ADR’s implicated in 5-17% of hospital admissions
• £500m per year on extra days in hospital due to medication errors
• Under us of evidence basedprophylactic drugs
• Approx £300m of wasted prescribed medicines per year

Question 2

Definition of medicine review

Answer 2

• A structured, critical examination of patients medicines with the objective of reaching an agreement with the patient about treatment, optimising the impact of medicines, minimising the number of medication-related problems and reducing waste

Question 3

The Five Rights of drug administration

Answer 3

1. Right patient
2. Right drug
3. Right dose
4. Right route
5. Right time

NB- Right paperwork

Question 4

Definition of medication errors

Answer 4

• A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professional, patient or consumer
• Such events may be related to professional practice, health care products, procedures and systems, including prescribing, order communication, product labelling, packaging and nomenclature, compounding, dispensing , distribution, administration, education , monitoring and use

Question 5

NPSA- Most common types of errors

Answer 5

Question 6

Never events list 2018

Answer 6

• Mis-selection of a strong potassium solution (could result in cardiac arrest)
• Administration of medication by the wrong route
• Overdose of insulin due to abbreviations or incorrect device
• Overdose of methotrexate for non-cancer treatment
• Mis-selection of high strength midazolam during conscious sedation

Question 7

NPSA-most common drugs associated with harm

Answer 7

Question 8

Types of review

Answer 8

• Level 1- Prescription review
  
  • Patient is not present with limited access to information
  • Rx in front of you, look at drug choice; contra-indications; interactions; quantity
• Level 2- Concordance and compliance review
  
  • MUR- done with the patient to check there understanding of medicines; any problems taking medicines or if experiencing side effects
  • No definitive medical notes
  • Useful for sorting many medical problems
• Level 3- Clinical medictation reveiw

-MURs are NOT clinical medication reviews

Question 9

Level 3 medication review

Answer 9

• Explains why a review is important
• Compile a list of ALL medication (NB-including OTC and herbal)
• Is there an active diagnosis for each item?
• Is drug therapy really necessary?
  
  • A big example is prochlorperazine in the elderly for dizziness, this drug can cause Parkinsonian (extrapyramidal) symptoms with long-term use, they get referred to check for Parkinson’s and subsequent administration of levodopa this can be avoided with the subtraction of prochlorperazine
• What are the therapeutic goals?
• Has the most appropriate drug been chosen?
• Is the drug being used correctly?
• Is the drug/disease being monitored appropriately?
• The occurrence of side effects
• Patients perception of purpose of medication
• Patients understanding of how medication should be taken
• Is the patient able to take medication?
• Any concerns/questions?

Question 10

Medicines Use Review (MUR)

Answer 10

• A structured concordance centered review with patients receiving medicines for long termconditions to establish a picture of their use of the medicines both prescribed and non-prescribed
• The review will help patients understand their therapy and it will identify any problems they are eexperiencing along with possible solutions

Question 11

Unintentional non-adherence

Answer 11

• Problems ordering/receiving repeat prescriptions
• Problems with packaging
• Difficulty reading labels
• Forgetting to take medication

Question 12

Tipton MM project

Answer 12

• Nearly 50% couldn’t read the labels
• Nearly 50% couldn’t open the bottles
• About 40% couldn’t remove tablets from blister packaging
• About 60% had some difficulty in remembering when to take medication
• 20% had difficulty swallowing medication
• About 40% had some medication that causes them some difficulty

Question 13

The incidence of medication errors

Answer 13

• EQUIP study- nearly 125,000 medication orders in 19 hospital trust in NW England found a mean prescribing error rate of 8.9%
• All grades of doctors made errors, but the highest rate (10.3%) by foundation year 2 doctors

Question 14

Medicines reconciliation

Answer 14

• Pharmacy technician led
• Obtain drug history using multiple sources
• Check allergy status
• Highlight discrepancies to the pharmacist for action
• Endorse a medication chart with BCN: Before, changed, new

Question 15

Review of medication chart

Answer 15

• Patient details- Name, Gender, Age (DOB), Hospital number and ward
• ALLERGY STATUS
  
  • What allergic to
  • What happens e.g. anaphylaxis vs diarrhoea
  • Interolence e.g. bradycardia with beta-blockers
  • NKDA (No Known Drug Allergy)
• Having looked at the chart, form an opinion as to diagnoses
• Iatrogenic disease- prochlorperazine example (Disease caused by drugs)
• What missing?

Question 16

Review: for each item

Answer 16

• Name
• Strength
• Dose
• The timing of administration- Flucloxacillin around meals, diuretics in morning
• Chart clearly marked for short-term/ Once a week drugs e.g. MTX
• Formulation
• Route of administration
• Additional administration instructions

Question 17

Strength

Answer 17

• Check carefully if there are several different stregnths of a preparation
• Esp, if the preparation is a liquid
• e.g. Morphine 10mg in 5mL and Morphine 100mg in 5mL

Question 18

Units- avoid abbreviations

Answer 18

• Mg and mcg easily confused
• write mcg as micrograms
• write as 500mg not 0.5g
• Write 100 micrograms not 0.1mg
• Units NOT iu e.g. 8 units safer than 8 iu could be read as 81 units

Question 19

Decimal points

Answer 19

• Never use a trailing zero
  
  • e.g. 1.0mg could be accidentally read as 10mg if decimal point is not clear (1mg is safer)
• Always use a leading zero

Question 20

Dose

Answer 20

• Is it clear and unambiguous?
• Can it be administered?
• If dose changed, is it clear?
• Has dose change been dated?
• Best practice to cross it off and re-write
• If unclear. clarify with prescriber and write clearly on the chart

Question 21

Dose and frequency- special considerations

Answer 21

• How is the drug excreted?
• Checken renal and hepatic function
• Elderly
• Paediatrics (Weight in Kg and Age)
• Length of treatment e.g. corticosteroid treatment- should it be stopped or reduced
  
  • Cytotoxic drugs

Question 22

Formulation

Answer 22

• Drugs that should be prescribed by brand- theophyline, insulin
• Plain vs MR
• Liquids vs Solids (elderly, post-stroke)
  
  • Specials
• Types of inhalers (dry powder, nebuliser)
• Paediatrics- Is it appropriate (ethanol, sorbitol)
• Is it suitable for NG (nasogastric) tube?

Question 23

IV infusion

Answer 23

• Infusions will be on a separate chart
• Look to see if anything attached to a patient
• Need to review along with the main chart- macrolides can interact
• Dose (check calculations)
• Use IV guide to check diluent, infusion volume and rate of administration
• Special consideration e.g. monitoring

Question 24

Alert 20: promoting safer practice with injectable medicines

Answer 24

• NPSA receives 800 incident reports a month concerning injectable medicines
• 24% of all medication incident reports
• 58% of incident reports leading to death and severe harm
• Mainly administration errors rather than prescribing errors

Question 25

Other separate chart- This is to improve safety as these items need specific instructions

Answer 25

• Gentamicin
• Vancomycin
• Sometimes insulin
  
  • Blood glucose values on chart and the prescription/s for insulin
• Warfarin Syringe drivers (compatibility)
• Ensure cross-reference is on main medication chart (no doses)